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Update on the pathological classification of gastritis

Hala El-Zimaity, M.D. M.S. Epidemiology McMaster University Hamilton, Ontario Canada

CLASSIFICATION
GASTRITIS GASTROPATHY

1. Acute 2. Chronic 3. Uncommon Forms

Chemical gastropathy (NSAID/Bile reflux)

100 Consecutive DU and 154 GU PATIENTS
VAMC, Houston

CAUSES OF PEPTIC ULCER
99%
Hp POSITIVE

92%

NSAID USER NSAID ONLY

Percent of Group

58% 30 % 0 % Duodenal Ulcer
Duodenal Ulcer

8%
Gastric Ulcer
El-Zimaity HMT

Case 1: 45 year old with dyspepsia Gastropathy = no acute inflammation (unless there is an erosion) El-Zimaity HMT .

El-Zimaity HMT .

and users are generally unaware of potential for adverse side effects. hemorrhage. peptic ulcer. frequently taken inappropriately. and even result in death. Can cause serious side effects including dyspepsia. OTC analgesics including NSAID are widely used. El-Zimaity HMT .Q: Should we care? 1. 2.

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27(12): 1348-54 El-Zimaity HMT . suggest it when suspected • Triad is only seen in 30 % of chronic NSAID users.not always see the triad. Incisura Q1: HOW OFTEN DO YOU SEE Chemical gastropathy is common. you will THE TRIAD? • Remaining 70%: – – – – edema foveolar hyperplasia only Fibrosis FH only or SMF-H only El-Zimaity et al Hum Pathol 1996. • Triad is most seen at incisura (less marked at other regions of the stomach).

Chronic 3. Uncommon Forms .CLASSIFICATION GASTRITIS 1. Acute 2.

GASTRITIS • ACUTE – H. pylori – Other Other bacteria (Heilmanni. pylori (chronic atrophic gastritis) – Autoimmune (body predominant) . mycobacteria) Syphilitic Viral Parasitic Fungal • Chronic – H.

GASTRITIS • ACUTE – H. pylori – Other Other bacteria (Heilmanni. mycobacteria) Syphilitic Viral Parasitic Fungal • Chronic – H. pylori (chronic atrophic gastritis) – Autoimmune (body predominant) .

Anatomy of The Stomach WHAT IS NORMAL? El-Zimaity HMT .

Anatomy of The Stomach corpus Acid antrum El-Zimaity HMT .

Anatomy of The CORPUS Antrum-corpus junction G cells D cells Parietal cells ECL corpus ECL Mucous acid antrum Chief corpus El-Zimaity HMT .

NORMAL CORPUS ECL Chief El-Zimaity HMT .

Anatomy of The ANTRUM Antrum-corpus junction G cells D cells Parietal cells ECL corpus Mucous antrum antrum El-Zimaity HMT .

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Acid Secretion Pathophysiology ACID Food Parietal cell ECL G cell Gastrin El-Zimaity HMT .

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pylori! • Yes. .Should you care? • If you speak “Arabic” you have H. you should care.

pylori corpus Acid antrum H. pylori starts its life in the antrum where it is less acidic El-Zimaity HMT .No bacteria likes too much acid including H.

No bacteria likes acid Starts in the antrum H. pylori surrounds itself with a bicarbonate cloud to counter gastric acidity (it produces urease which converts urea (abundant in saliva & gastric juices) to ammonia and bicarbonate) C=0(NH2)2 + H+ +2H20 --urease--> HCO3.+ 2(NH4) .

Acid Secretion Pathophysiology ACID Food/H. pylori Parietal cell ECL G cell Gastrin El-Zimaity HMT .

Duodenal Ulcer 100 Parietal cells Parietal cell Acid G cell 100 G cells El-Zimaity HMT ACID Gastrin .

pylori Inflammation in antrum only ACID 1 Zone 2 3 Body Zone 1 2 3 Antrum HMT El-Zimaity .Inflammation Depth-Duodenal Ulcer MNC PMN H.

Inflammation Depth-Duodenal Ulcer MNC H. pylori PMN H. pylori Zone toxins 1 2 3 Cytokines Massive inflammatory response Antrum Destroy stomach El-Zimaity HMT .

Acid Secretion GASTRIC ATROPHY Destroyed corpus = no acid = bacteria moves proximal ACID Food/H. pylori Parietal cell Parietal cell ECL G cell Gastrin El-Zimaity HMT .

pylori Inflammation in both antrum and corpus ACID 1 Zone 2 3 Body Zone 1 2 3 Antrum HMT El-Zimaity .Inflammation Depth-Gastric Ulcer MNC PMN H.

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pylori infection missed) – You will help him develop gastric atrophy El-Zimaity HMT .g. pylori positive – Receives acid suppressor therapy without treating the infection (e. GERD patient and H.Why is this important? • If patient is H.

pylori Parietal cell Parietal cell ECL ECL ECL HYPERGASTRINAEMIA G cell G cell G cell Gastrin Gastrin Gastrin ECL HYPERPLASIA El-Zimaity HMT .Acid Secretion PPI treatment = high pH ACID Food/H.

ANTRAL MUCOSA Before After PPI El-Zimaity HMT .

CORPUS MUCOSA VAMC. Houston Before After PPI El-Zimaity HMT .

Corpus gastritis Pan-atrophic El-Zimaity HMT .Gastritis Stages Antral Predom.

El-Zimaity et al Am J Gastro 2001.Gastritis Stages B B A A A B B A Corpus atrophy Normal corpus Normal antrum A A Atrophic border (antral corpus junction) moves proximally and towards greater curve with disease progression.96:666-672 El-Zimaity HMT .

1:87-97 El-Zimaity HMT .Endoscopic Recognition of the Atrophic Border Kimura and Takemoto 1969 Eastern (Japanese) beliefs Endoscopy 1969.

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Lesser curvature Greater curvature Advancing atrophic border El-Zimaity HMT .

Is it in the antrum only or antrum and corpus? 2. If in the corpus.3 questions to answer if you already decided it is H. pylori 1. Is there corpus atrophy? El-Zimaity HMT . is inflammation superficial or deep? 3.

increased fibrosis) – Replacement of what is normally there (with intestinal metaplasia or pseudopyloric metaplasia) .Gastric atrophy • Absence of what is normally there: – Simple absence of glands (reduced thickness.

Phenotypic corpus Phenotypic antrum Intestinal metaplasia I & II Intestinal metaplasia III Tumor Atrophy in Gastric cancer (Intestinal type) (a) advancing atrophic border (b) total atrophy of antrum 12 % n=2 88 % n = 14 total atrophy of the antrum advancing atrophic border El-Zimaity HMT .

Isolated intestinal metaplasia = not important El-Zimaity HMT .

Continuous sheets of atrophy (IM and/PPM) is ominous irrespective of IM subtype El-Zimaity HMT .

Continuous sheets of atrophy (IM and/PPM) is ominous PGI in Pseudopyloric metaplasia El-Zimaity HMT .

• We know how to recognize intestinal metaplasia • How do we recognize pseudo-pyloric metaplasia? .

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Pepsinogen I (PG I) Anatomic Corpus (pseudopyloric metaplasia) ANATOMIC CORPUS PGI PGI El-Zimaity HMT .

GASTRIC ANTRUM PEPSINOGEN I GASTRIN El-Zimaity HMT .

Pepsinogen I (PG I) Anatomic Corpus (pseudopyloric metaplasia) ANATOMIC CORPUS Gastrin El-Zimaity HMT .

2005.PSEUDO-PYLORIC METAPLASIA PPM starts as early as 9 years old.58(11):1189-93. Cardona et al Journal of Clinical Pathology. El-Zimaity HMT . Atrophy always starts at antral corpus junction and moves proximally and towards the greater curve.

Recognize all forms of atrophy (absence of normal or replacement with intestinal metaplasia and/or pseudopyloric metaplasia) El-Zimaity HMT .Two things to remember 1. Look for the Atrophic Front (starts at antral corpus junction) 2.

What about Pernicious Anaemia? • Scandinavian decent • Auto immune gastritis • Parietal cell and Intrinsic Factor antibodiesmegaloblastic anemia • Three to five fold increased risk of gastric cancer El-Zimaity HMT .

GASTRITIS PATTERN PA El-Zimaity HMT .

pylori era.pernicious anaemia Big overlap in the literature since most PA studies were done before H. some deny its existence! El-Zimaity HMT .

pylori gastritis El-Zimaity HMT .In any H. Pylori Gastritis • H. pylori positive patient • Use patient’s serum as primary antibody • Parietal cells stain dark blue = autoantibodies in every day H.

G cells increase in number Acid production drops much faster in PA. ECL cells keep growing + + + trin as G 2.PERNICIOUS ANEMIA D Parietal cell antibodies Many folds higher 1. so. pylori and associated inflammation moves proximally much faster. H. Parietal cells disappear early D - ECL + P Gastric acid 3. El-Zimaity HMT G .

Chromogranin Grimelius El-Zimaity HMT .

PERNICIOUS ANAEMIA Corpus atrophy with gastric cancer risk (intestinal type) ECL hyperplasia and eventually carcinoids El-Zimaity HMT .

QUESTIONS TO ANSWER IN GASTRIC BIOPSIES? 1. Is it normal? Is it a gastritis or a gastropathy? 2. pylori but no bacteria found? 3. Is there atrophy? . Why it looks like H.

Landmark for NORMAL lymphoid infiltrates muscularis mucosae .

Lymphoid infiltrate: Loose next to muscularis mucosae = Normal El-Zimaity HMT .

.Lymphoid Follicles in H. mantle. pylori infection Pre-treatment Have marginal zone. followed by mantle zone. and follicle center Post treatment Lymphoid tissue first disappear from marginal zone.

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If you found this in a 45 year old with dyspepsia (mucosa looks El-Zimaity HMT .

Safety Pin Appearance HP El-Zimaity HMT .

the gastric pH increases which allows other bacteria to survive in the stomach. pylori. Look for squiggle bacteria with safety pin appearance. • Make sure you are really looking at H.NOT ALL BACTERIA IN THE STOMACH ARE H. . pylori • With PPI use.

lymphocytic gastritis) .few bugs Focal chronic active colitis .pylori negative gastritis • • • • Proton pump inhibitors (omeprazole etc.) Recent antibiotics or eradication therapy Missed organisms .g.Crohn’s disease • Other types of gastritis (e.Causes of (apparent) H.

GASTRITIS 1. Uncommon Forms Lymphocytic Eosinophilic Crohn's disease Sarcoidosis Isolated granulomatous . Acute 2. Chronic 3.

• Ratio of 25 CD3+ IEL/100 epithelial cells (focal). • H. • Usually accompanied by lamina propria plasmacytosis • Celiac Disease. pylori (low H. Menetrier’s Disease. Gastric Lymphoma. pylori count) El-Zimaity HMT .Lymphocytic Gastritis • Protein loss.

Lymphocytic Gastritis

El-Zimaity HMT

Crohn’s Gastritis
Same as any other part of the gastrointestinal tract 1.Focal enhanced inflammation 2.Granulomas

El-Zimaity HMT

Gastritis (acute and chronic) is multifocal HMT El-Zimaity

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Granuloma El-Zimaity HMT .B. Focally enhanced gastritis (acute and chronic) 2. pylori • Granuloma basics: – – – – IBD T.Granuloma’s in the Stomach • H. Sarcoid Foreign body Crohn’s 1.

Pangastritis. dysplasia or cancer)? . Focal) 2.g. Cardiac.Reporting gastritis 1. Is it a gastritis or a gastropathy? 3. Are there epithelial/vascular changes (e. Where am I? (Site . Oxyntic.Antral.